cms hospital conditions of participation (cops) 2011 what hospitals need to know about grievances
TRANSCRIPT
CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS)
2011
What Hospitals Need to KnowAbout Grievances
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Speaker Sue Dill Calloway RN, Esq. CPHRM
AD, BA, BSN, MSN, JD
President
Patient Safety and Education
5447 Fawnbrook Lane
Dublin, Ohio 43017
614 791-1468
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Objectives
Discuss the requirement that hospitals must follow the CMS CoP regulations on grievances if they receive Medicare reimbursement
Recall that CMS requires hospitals to have a grievance committee
Describe how hospital boards must approve the grievance policy and procedure
Recall that the Joint Commission has standards on complaints
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Regulations first published in 1966 Many revisions since with final interpretive guidelines issued June 5,
2009 (Tag 450 changed), and Anesthesia standards December 11, 2009 (minor revision Feb 5, 2010, May 21, 2010 and February 14, 2011) and Respiratory and Rehab Orders August 16, 2010 and Visitation regulations became effective January 19, 2011
Published in the Federal Register first as 42 CFR Part 482 1
CMS then publishes Interpretive Guidelines and some have survey procedure
Hospitals should check this website once a month for changes 2
1www.gpoaccess.gov/fr/index.html 2www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
The Conditions of Participation (CoPs)
Respiratory and Rehab Orders Published in the August 16, 2010 Federal Register
Allows a qualified licensed practitioner who is responsible for the care of the patient (such as a PA or NP)
Who is acting within their scope of practice under state law
Can order respiratory or rehab order (physical therapy, occupational therapy, speech)
Must be privileged (authorized) by the MS
Must have hospital P&P to allow also6
Visitation Effective January 19, 2011
Must rewrite policy on visitation including visiting hours in ICU
Must inform each patient of their visitation rights
Must include any restrictions on those rights
Can not restrict or deny visitation privileges on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity or disability
For example same sex partner may present visitation advance directive
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Federal Register Visitation Changes
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Interpretative guidelines are on the CMS website1
Look under state operations manual (SOM)
Appendix A, Tag A-0001 to A-1163 and 370 pages long Hospitals should also check the CMS transmittals once a
month for changes 2
Critical access hospitals have a separate manual, appendix W, which is 206 pages
All the manuals are found on CMS website 2
1www.cms.hhs.gov
2http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
3 http://www.cms.gov/Transmittals/01_overview.asp
CMS Hospital CoPs
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www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
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http://www.cms.gov/Transmittals/01_overview.asp
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The Patient’s Rights section contains the grievance provisions which starts at Tag 118
Establishes minimum protections and rights for patients
Examples: The right to notification of rights and exercise of rights
The right to privacy and safety, confidentiality of medical records and to be free from unnecessary R&S
Right to have advance directives followed
The right to pick who will visit them
Patient Rights Standards 0115-0214
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All hospitals that participate in the Medicare/Medicaid program
Most hospitals in this country except VA hospitals
All parts and locations of the hospital
Includes short term, surgical, psychiatric, rehabilitation, long term care, children’s and alcohol drug facilities
Does not apply to CAH
However, CAH should have policy and include some of these requirements
Applies whether or not a hospital is accredited by TJC, AOA, DNV Healthcare
Who Does This Apply?
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Notice of Patient Rights and Grievance Process
Hospital must ensure the notice requirement of patient rights is met
The rights must be provided in a manner the patient will understand The issue of low health literacy or low English proficiency (LEP) such
as a patient who does not speak English
20% of population reads at a fifth grade level
TJC has standards on complaints which is discussed later
Must have P&P to ensure patients have information necessary to exercise their rights
Standard # 1 Tag A-0116
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Rule #1 - A hospital must inform each patient of the patient’s rights in advance of furnishing or discontinuing care
Must protect and promote each patient’s rights
Must have P&P to ensure patients have information on their
All patients, inpatients and outpatients, must be informed of their rights
Grievance requirements must appear in the written copy of the patient rights
Notice of Patient Rights 116
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When appropriate, this information is given to the patient’s representative if the patient is not competent
Document reason such as patient unconscious, and who is signing such as guardian, DPOA, parent if minor child, etc.
Consider having a copy of the patients rights on the back of the general admission consent form and acknowledgment of the NPP
Include the sentence that patient acknowledges receipt of their patient rights or document when written patient rights statement is given
Notify Patient of Their Rights
Survey Procedure 116 This standard has a survey procedure section
It is instructions to the surveyor on what they are suppose to do
The surveyor is to ask patients if the hospital informed them about their patient rights
Be sure registration clerk or nurse informs the patient of their rights and this is documented
Surveyor is to determine the hospital’s policy for notifying them of their patient rights
This includes both inpatients and outpatients
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Rule #2 - A hospital must ensure interpreters are available
Make sure communication needs of patients are met
Recommend qualified interpreters or certified deaf interpreters
Must comply with Civil Rights law and OCR
Made need to consider if discussing a grievance with LEP patient
See 2011 standards on patient centered communications
Interpreters
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Rule #3 - The hospital must have a process for prompt resolution of patient grievance
Patients should have a reasonable expectation of care and service
Hospital must inform each patient where to file a grievance Consumer advocate, risk management department etc.
Provide phone number to contact designated person
Patients have the right to have their concerns addressed in a timely, reasonable, and consistent manner
Grievance Process A-0118
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Grievance Process A-0118
CMS provides a definition which you need to include in your policy Use the CMS CoP definition of grievance
TJC does not have a definition of complaint in 2011 glossary
If TJC accredited, combine P&P with complaint section at RI.01.07.01 The patient and family have a right to have
grievances/complaints reviewed by hospital
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Definition: A patient grievance is a formal or informal written or verbal complaint
When the verbal complaint about patient care is not resolved at the time of the complaint by staff present
By a patient, or a patient’s representative,
Regarding the patient’s care, abuse, or neglect, issues related to the hospital’s compliance with the CMS CoP
Or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489.
Grievance Process A-0118
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Remember it is not a grievance if resolved by “staff present” so take care of concerns immediately
Expanded definition of what is meant by “staff present”
Definition includes any hospital staff present at the time of the complaint or staff who can quickly be at the patient’s location to resolve the patient’s complaint Nursing administration, nursing supervisors, patient
advocates, nurse, or other appropriate staff member
Document the concern and how it was immediately resolved in medical record if patient is still an inpatient
“Staff Present” Grievances
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Hospitals should have process in place to deal with minor requests in more timely manner than a written request Examples: Change in bedding, housekeeping of room,
and serving preferred foods
Does not require written response
If complaint cannot be resolved at the time of the complaint or requires further action for resolution, then it is a grievance
Then all the CMS requirements for grievances must be met
Grievances A-0118
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If someone other than the patient complains about care or treatment:
First need to contact the patient and ask if this person is their authorized representative
If not an authorized representative, then it still may be a complaint under the Joint Commission standard
However, the July 1, 2009 changes brought TJC and CMS standards closer but not completely cross walked
Note that TJC calls it complaints which CMS uses the terminology of grievances
Patient or Their Representative
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It is not a grievance by CMS”s definition if the patient is satisfied with the care but a family member is not
If person is the authorized representative of the patient then need to obtain patient’s permission to discuss medical record information with that person because of the HIPAA law
New changes in HIPAA enforcement so need to do this right
Document patient’s permission to discuss PHI with their representative
Be sure to document both of these elements in the risk management file or other file
Patient or Their Representative
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Billing issues are not generally grievances unless a quality of care issue
A written complaint is always a grievance whether inpatient or outpatient
Email and fax is considered to be a written grievance
Information on patient satisfaction surveys is generally not a grievance
Unless patient asks for resolution or unless the hospital usually treats that type of complaint as a grievance
Grievances 0118
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If complaint is telephoned in after patient is dismissed then this is also considered a grievance
All complaints on abuse, neglect, or patient harm will always be considered a grievance
Exception is if post hospital verbal communication would have been routinely handled by staff present
This is a minor exception and suggest you use exact language from Tag 118 in your P&P
If patient asks you to treat as grievance it will always be a grievance
Do not have to use the word “grievance”
Grievances 0118
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If issue is resolved promptly then it is NOT a grievance
Conduct in-services on importance of “PR” and Good Customer service and get staff to deal with patient’s request timely
Less likely to have complaints and grievance if good patient experience
Monitor patient satisfaction surveys
Disgruntled patients will contact CMS, Joint Commission, state department of health, QIO, OIG, OCR, OSHA, DNV, AOA, and others
Grievance Process
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CMS instructs the surveyors to do the following
Review the hospital policy to assure its grievance process encourages all personnel to alert appropriate staff concerning grievances
How do you do this? – standard form, education in orientation, yearly skills lab etc.
Hospital must assure that grievances involving situations that place patients in immediate danger are resolved in a timely manner
Conduct audits and PI to make sure your facility is following its grievance P&P
Grievance Process Survey Procedure
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Surveyor will interview patients to make sure they know how to file a grievance
Including the right to notify the state agency Provide phone number of state department of health and QIO
Remember TJC APR requirements regarding unresolved patient safety concerns
So include all three in your patient rights statement
Should be provided to the patient or their representative in writing
Patient admission representative points out section in general consent form and NPP on grievances
Grievance Process Survey Procedure
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Rule #4 The hospital must establish a process for prompt resolution
Inform each patient whom to contact to file a grievance by name or title
This must include patient representative and phone number and address of state agency
Does operator know who to route calls to?
Do you have a form accessible to all?
Grievance Process A-0119
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Rule #5 The hospital’s governing board must approve and should be responsible for the effective operation of the grievance process
Elevates issue to higher administrative level
Have a process to address complaints timely
Coordinate data for PI and look for opportunities for improvement
Data on grievances must be incorporated into the PI program n(118)
You must read this section with the next rule
Most boards will delegate this to hospital staff to do
Grievance Process A-0119
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The hospital’s board must review and resolve grievances, unless it delegates the responsibility in writing to the grievance committee
Board is responsible for effective operation of grievance process making sure grievance process reviewed and analyzed thru hospital’s PI program
Grievance committee must be more than one person and committee needs adequate number of qualified members to review and resolve
CMS does not say what their function is or how many times to meet
Rule #6 A-0119-120
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Make sure your governing board has approved the grievance process
Look for this in the board minutes or a resolution that the grievance process has been delegated to a grievance committee
Consider attaching the board minutes or resolution to the policy or reference it to the date of the board meeting
Does hospital apply what it learns?
Remember to evaluate the system analysis theory to determine if system problem
Grievance Survey Procedure
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Rule #7 – The grievance process must include a mechanism for timely referral of patient concerns regarding the quality of care or premature discharge, to the appropriate QIO
Each state has a QIO under contract from CMS and list of QIOs1
QIO or Quality Improvement Organizations are CMS contractors who are charged with reviewing the appropriateness and quality of care rendered to Medicare beneficiaries in the hospital setting
1http://www.qualitynet.org/dcs/ContentServer?pagename=Medqic/MQGeneralPage/GeneralPageTemplate&name=QIO%20Listings
Grievance Process-A-0120
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QIOs make hospitals aware of fact they have a complaint regarding the quality of care, a disagreement with coverage decision or wish to appeal a premature discharge
Patient can ask that complaint be forwarded to the QIO by the hospital or can complain directly to the QIO
Hospitals do not need to forward to the state QIO unless the patient specifically requests
Consider in the patient rights section to request patient give you an opportunity to address it first
QIO Quality Improvement Organizations
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Must have a clear procedure for the submission of a patient’s written or verbal grievances
Surveyor will review information to make sure it clearly tells patients how to submit a verbal or written grievance
Surveyors will interview patients to make sure information provided tells them how to submit a grievance
Must establish process for prompt resolution of grievances
Grievance Procedure 121
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Rule #8 – Hospital must have a P&P on grievance
Specific time frame for reviewing and responding to the grievance
Grievance resolution that includes providing the patient with a written notice of its decision, IN MOST CASES
The written notice to the patient must include the steps taken to investigate the grievance, the results and date of completion
Hospital Grievance Procedure 0122
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Facility must respond to the substance of each and every grievance
Need to dig deeper into system problems indicated by the grievance using the system analysis approach
Note the relationship to TJC sentinel event policy and LD medical error standards, CMS guidelines for determining immediate jeopardy, HIPAA privacy and security complaints, and risk management/patient safety investigations
Hospital Grievance Procedure
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Timeframe of 7 days is considered acceptable
If not resolved or investigation not completed within 7 days must notify patient still working on it and hospital will follow up
Most complaints are not complicated and do not require extensive investigation
Surveyor will look at time frames established
Must document if grievance is so complicated it requires an extensive investigation
Grievances
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Hospital must give patient a written response
Explanation to the patient must be in a manner the patient or their legal representative would understand
The written response must contain the elements required in this section and not statements that could be used in legal action against the hospital
Written response must include the steps taken to investigate the complaint
Surveyors will review the written notices to make sure they comply with this section
Grievances A-0123
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Written notice must be communicated in language and manner that can be understood
CMS says if patient emailed you a complaint, you may e-mail back response, if hospital allows
Must maintain evidence of compliance with the grievance requirements
Grievance is considered resolved when patient is satisfied with action or if hospital has taken appropriate and reasonable action
Grievances A-0123
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TJC has complaint standard RI.01.07.01 with changes 7-01-09 and 2010 standards
Patient and family have a right to complaints and grievances (C&G), 20 EPs
Need a process and make sure the patient is aware the process which must include time frames (EP 19)
Resolve G&C that hospital recognizes as significant and acknowledge receipt of the complaint
TJC Complaint Standard
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Notify the patient of follow up
Provide patient with phone number and address to file a CG with the State Agency (SA) and QIO (for quality of care issues or premature discharge)
Allow to voice CG freely without being subject to coercion, discrimination or unreasonable interruption in care No similar CMS section
Must give written response with steps taken, results, date of completion, etc.
TJC Complaint Standard
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RI.01.07.01 Complaints & Grievances
Standard: patient and or her family has the right to have a complaint reviewed, (RI 2.120 previously),
TJC calls it complaints and CMS calls it grievances
EP1 Hospital must establish a complaint and grievance (C&G) resolution process,
See also MS.09.01.01, EP1,
EP2 Patient and family is informed of C&G resolution process,
EP4 Complaints must be reviewed and resolved when possible,
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RI.01.07.01 Complaints & Grievances
EP6 Hospital acknowledges receipt of C&G that cannot be resolved immediately Hospital must notify the patient of follow up to the C&G,
EP7 Must provide the patient with the phone number and address to file the C&G with the relevant state authority,
EP10 The patient is allowed to voice C&G and recommend changes freely with out being subject to discrimination, coercion, reprisal, or unreasonable interruption of care,
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RI.01.07.01 Complaints and Grievances
EP 17 Board reviews and resolves grievances unless it delegates this in writing to a grievance committee (eliminated but still CMS requirement),
EP 18 Hospital provides individual with a written notice of its decision which includes (DS);
Name of hospital contact person
Steps taken on behalf of the individual to investigate the grievance
Results of the process
Date of completion of the grievance process
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RI.01.07.01 Complaints
EP19 Hospital determines the time frame for grievance review and response(DS)
EP20 Process for resolving grievances includes a timely referral of patient concerns regarding quality of care or premature discharge to the QIO
EP21 Board approves the C&G process (eliminated but still CMS standard)
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Have a Policy to Hit All the Elements
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Use a Form to Collect Information
CMS Proposed New Rule
CMS proposed new rule for notifying beneficiaries of their right to file a quality of care complaint
Give beneficiaries written notice of their right to contact their state QIO or Quality Improvement Organization
Also include
Currently, only hospital inpatients receive this information
Includes 10 facilities such as clinics, CAH, LTC, hospices, home health agencies, ASCs, comprehensive outpatient rehab facilities, portable X-ray services and rural health clinics
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Medicare Patients, Complaints and the QIO
The proposed rule was published in the Federal Register on February 2, 2011
at http://www.gpo.gov/fdsys/pkg/FR-2011-02-02/pdf/2011-2275.pdf
QIOs must conduct a review of all written complaints about the quality of care for Medicare patients only
Current hospital CoP includes a requirement that the grievance process must include a mechanism for timely referral to the QIO of beneficiary concerns regarding quality of care
Must also give Medicare patients a copy of their IM Notice
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Medicare Patients, Complaints and the QIO
Since 9th scope of work started August 1, 2008, QIOs have received 6,379 inpatient and 4,1116 outpatient requests
Feel number is inadequate because Medicare patients do not know they can complain to their QIO
Expanding now that Medicare patients, or their representative, will receive written notice at the start of their care, of their right that they can complain about quality of care issues to the QIO in other settings
Such as time of admission or in advance of furnishing care57
Medicare Patients, Complaints and the QIO Medicare patient who is competent can also decide to have
the written notice given to their surrogate such as a friend or family member
Remember if need to use an interpreter for limited English proficiency (LEP) or deaf/hard of hearing patients
Unless patient signs a waiver declining interpreter
Remember the 2011 TJC patient centered communication standards
Also 7 of the 10 providers must include information to contact the state agency
Hospitals, HH, RHC, CORF, FQHCs, Hospices, clinics58
Specific Requirements
For example an ASC, hospice, hospitals, etc. would have to do the following;
Give the patient a written notice of their right to notify the QIO
Must include at the time of admission or in advance of furnishing care
Must include name, telephone number, email address, and mailing address
Must document in the medical record that the notice was given
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Proposed FR February 2, 2011
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The End Questions?
Sue Dill Calloway RN, Esq. CPHRM
AD, BA, BSN, MSN, JD
President
Patient Safety and Education
5447 Fawnbrook Lane
Dublin, Ohio 43017
614 791-1468
6161
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2011 Changes MR Must Contain
New in 2011 to improve patient centered communication by TJC
Qualifications for language interpreters and translators will be met through proficiency, assessment, education, training, and experience
Hospitals need to determine the patient’s oral and written communication needs and their preferred language for discussing health care under PC standard
Hospital will communicate with patients in a manner that meets their communication needs
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2011 Changes MR Must Contain
Collecting race and ethnicity data under RC.02.01.01 EP1
Collecting language data under RC.02.01.01 EP1
The patient’s communication needs, including preferred language for discussing health care
If the patient is a minor, is incapacitated, or has a designated advocate, the communication needs of the parent or legal guardian, surrogate decision-maker, or legally authorized representative is documented in the MR
The patient’s race and ethnicity